Failure to Ensure Proper Supervision and Evaluation During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure proper supervision and evaluation during resident transfers involving mechanical lifts. Observations showed that two CNAs performed a transfer using a sit-to-stand lift for a resident whose most recent lift assessment, dated several months prior, indicated that a lift was not required. No updated lift assessment was found in the clinical record. The care plan for this resident, however, indicated the need for a sit-to-stand lift with two staff assistance at all times. Additionally, an incident report documented a fall involving another resident when a CNA used the sit-to-stand lift alone, contrary to facility policy requiring two staff for all mechanical lift transfers. Staff interviews revealed inconsistent training and understanding regarding lift use, with new CNAs often being trained informally by peers rather than through structured education or competency checks. Further review of staff training records showed incomplete documentation of mechanical lift training for new hires, and the DON acknowledged uncertainty about how lift requirements were communicated to CNAs. The DON also indicated that care plan updates and lift assessments were not consistently current. These findings demonstrate a lack of consistent evaluation, documentation, and staff education regarding the safe use of mechanical lifts, resulting in accident hazards and inadequate supervision during resident transfers.